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System Director of Quality
3 months ago
Description for Internal Candidates
The System Director of Quality is responsible for administering, directing and coordinating the functions and activities of Quality Improvement, Patient Safety, Patient Relations, Infection Prevention, Accreditation, and Clinical Data Review under the Quality Department banner. The System Director of Quality utilizes their expertise to support the decision-making of the CMO/President and other Senior Leaders. The System Director of Quality is responsible for leading their team of specialists and data analysts to perform the functions of the office with excellence. Reports directly to the Chief Medical Officer/President of Regional Medical Center.
Responsibilities for Internal Candidates
Duties include but are not limited to:
- Manages processes involved in the collection and analysis of quality outcomes and implementation of quality improvement activities in collaboration with clinical leadership, safety teams and Quality Committees across the St. Peter’s Health system.
- Collaborating with clinical leaders and front line staff as necessary to move quality improvement projects forward.
- Communicating with physicians and clinical staff the necessary information to meet required reporting requirements, and for communicating and reporting any issues of not meeting the measures.
- Seeking to listen and understand first to better decision-making around solutions to quality concerns.
- Monitoring the appropriateness of patient care based on evidenced based medicine outcomes and clinical guidelines.
- Directs internal audits of key processes and leads all accreditation activities for the organization.
- Develops and implements systems to monitor, manage, measure and communicate clinical outcomes to staff, physicians and management team members.
- Works closely with clinical teams to identify significant variances in care pathways and to help resolve and minimize variances through effective consultation and coordination with staff.
- Provides senior leadership with expert advice and guidance regarding decisions around quality related improvement efforts and accreditation/ISO.
- Being or becoming within 12 months, the system expert in DNV accreditation and QMS.
- Leading the development and maintenance of the QMS, DNV Accreditation and the ISO 9001:2015 Certification.
- Developing visual graphs and displays of Quality and Regulatory data with an attached executive summary for all monthly committee, department and Board meeting books.
- Serves as the St. Peter’s Health System’s quality liaison to regulatory bodies, accreditation agencies and to other external regional or community stakeholders.
- Manages the expenses and budgets of the Quality Department.
Qualifications for Internal Candidates
KNOWLEDGE/EXPERIENCE : 5 years in dedicated healthcare quality, accreditation and/or safety related work required and can include experience as a clinician with evidence of leading quality improvement initiatives. Clinical experience preferred. Experience with DNV GL Healthcare accreditation requirements regarding quality management is required. Experience with the operations of the healthcare industry and healthcare delivery systems is required. Background in Quality Improvement principles and techniques is required. Ability to review the medical record in order to obtain clinical information to perform concurrent and/or retrospective data abstraction/reviews is required. Background in EPIC Quality Systems preferred. Demonstrated excellent communication, presentation and interpersonal skills required. Demonstrated ability to work independently, prioritize work and meet deadlines required. Demonstrated ability to effectively present data and information to Senior Leadership, Committees and Boards required. Knowledge of statistical and data analysis preferred and will be required within 12 months of hire. Effective Leadership and Management skill is essential to be successful in this position.
EDUCATION : B achelor’s degree in a business or health care-related field or a Baccalaureate Science Nursing (BSN) required. Master’s degree in a business or health care-related field or a Masters Science Nursing (MSN) preferred. Must have at least 5 years of direct experience in healthcare quality assurance/performance improvement.
LICENSE/CERTIFICATION/REGISTRY : CPHQ certification strongly preferred. RN license preferred.
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